The following is the graduation speech I wrote for my university:
Dear fellow students, parents, brothers and sisters, children, faculty and staff: welcome to the graduation ceremony for the class of 2009. It is one of the four great days of medical school and I am honored to be given the chance to speak with you about the achievements of the 152 people who are graduating today. As a group we have published papers, presented at conferences, nailed a one-in-a-million diagnosis, gotten married, had children, and won the coed intramural volleyball championship.
These past four years will certainly be memorable to me for a very long time. Although it has taken us only four years to complete medical school, some of us have aged much more than that. Whenever I am at a bar and ordering a drink, I pull out my driver’s license to show my age only to have the bartender say, “Don’t bother.”
People talk about medicine as if it’s a calling. I don’t know if that’s true, but I do know that this is the field for me. Nothing else gets me up in the morning so early and so eager as medicine does. Every day is a chance to learn something new.
With all that learning and training comes an awesome responsibility. As doctors we will have great authority and power in which we can literally decide the fate of other people. With this role comes respect, prestige, and yes, even money. We have made many sacrifices to get to this point. We have given up the best years of our lives to sit in classrooms learning the nuances of the human body. Some of us have given up on relationships. We’ve held off on having children. We’ve suspended other careers. And yet the greatest example of self-sacrifice as a physician is to give away all of that talent for free.
A month ago I took my fourth trip overseas as part of a medical mission. Some of you here have gone on international trips as well. You’ve seen the worst hand that humanity can deal. You’ve gone to an impoverished region where poor people who cannot speak English receive your services at no cost to them. You then returned to this city where you worked with poor people who cannot speak English and received your services at no cost to them. And yet, somehow that trip was more meaningful. And you’ve realized that’s what gets you up in the morning. You can have an impact on the lives of others. Whether you decide to ultimately practice here, elsewhere in the country, or abroad, your decision to become a physician should be one of your guiding purposes in life.
Unfortunately, not everyone feels the same. So many of my classmates have gotten this far only to realize that they have made a very expensive mistake. They entered medical school in search of prestige, money, or the approving of their parents. Nothing is worse than a person who says, “My mother’s son is a doctor.”
I know of several people who now openly admit that they dislike medicine. Unfortunately, they are now more than $200,000 in debt and cannot leave the profession. They are now stuck in this job field for no other reason than economics. I think that many physicians are similarly trapped because so few other careers have a high enough payout to clear the necessary debt that comes with this training. So to all of our younger brothers and sisters who are here tonight and thinking of becoming doctors: know what you’re getting into. This is an 80-hour-a-week job that comes with high emotional strain, abuse from those higher up, abuse from patients, threats of litigation, inability to predict whether or not you will be paid, and a constant worry that maybe you didn’t make the right decision with that last patient. But if you like science, are good with people, and enjoy solving puzzles, then maybe you should consider a career in medicine.
I’ve brought something today. Here is my old white coat. I’ve worn this jacket almost every day over the past year. It is covered with stains from various bodily fluids, food from the cafeteria, and a mysterious orange color that I have yet to identify. Although I wash it regularly it will continue to be synonymous in my mind with transference of infections from one patient to another. It’s a reminder of the power and trust that physicians instantly hold with all patients. It’s the universal symbol of healing and knowledge. And yet when it comes right down to it, it is barely more than a glorified bed sheet with buttons and pockets.
Sociologists tell us that whenever there is a life-altering event, a ceremony is used to celebrate that change. Whether it be the birth of a child, a wedding, or a funeral, we use ceremonies to signify that something important has just happened. In a few moments we’re about to have a ceremony to signify our graduation. But it should be something much more than a party. Once we walk across this stage our lives will be forever changed, for better for worse, with all the rights and responsibilities of someone with the title M.D.
There will deservedly be fear as we enter the next phase of our training. We will constantly question ourselves: did I study this disease enough? Did I get all the information that I needed from the patient? Am I the right person for the job? Am I doing the right thing? As Dr. B______ once told us, every time you start to write a prescription, your hand should tremble.
Fear does not need to be limiting. A mystic once told the story of a group of lions who decided to attack a herd of zebras. The older, weaker lions went to the far side of the zebras and began roaring. The zebras, upon hearing the roars, became frightened and ran away from the sounds—right into an ambush of the younger, stronger lions. The moral of the story is that whenever you become scared, run towards the roars.
We can use that fear for good. We can say: I did study this disease enough. I am confident I got enough information from the patient. I am indeed the right person for the job. I know that I am doing the right thing. Medicine then becomes a focus on lifelong learning and purpose rears its head once again. And once we realize that what we do has a greater effect on our patients then on ourselves, I think we have learned the greatest lesson that medical school can teach. Kicking and screaming along the way, the University has taught us how to be doctors.
I look at this old white coat and realize that I have finished some of the hardest years of my life. I can smile knowing that I don’t have to take a shelf exam ever again. I also frown knowing that one day my signature will be on the prescription pad or the order form and that I’ll be the one who’s held accountable. I look at it and wonder where the last few years have gone.
I look at this old white coat knowing that one stage of my training is almost finished and know that I am about to embark upon the next journey. And whether medicine is a calling or simply an interesting job, I look at this old white coat knowing that soon we’re all going to be doctors.
As I’m coming up on the end of medical school, I started reading old comments on this blog. Some people generate discussion, others criticize, someone else might say something funny, and then there are those times when I read a comment and think to myself, what the hell was he thinking? So now, I present my weirdest comments from the past two years.
By far my most popular post has been about the difficulty in getting into medical school . Despite my constant pleas in which I beg people not to ask me about their individual circumstances-such as “what are my chances of getting into medical school”—I am regularly hit by high school students who clearly know nothing about what doctors do. Calah writes:
So, is it better for a girl to be a doctor or nurse? Nurses make less, for doing the same thing. But, doctors have to go to school for soooo long. Is it worth it? What if u want a family? After you graduate, are doctor and nurses working hours that different, especially if u want a family?
What the hell are you talking about? Doctors and nurses have very different jobs and work different hours. I don’t watch many medical TV shows, but does ER tell us that doctors and nurses do the same thing?
Phuong follows up with,
I think that if you truly wanted to be in the medical field, gender doesn’t matter. I rather be a doctor, because they make more, and it seems more fun anyways (BTW I’m a girl). I also thought that being in school to be a doc, you’ll get out at 30 years old or something. and that sucks….but i think that most doctors, have families, and most of them meet their loved ones while in school or something. That’s what i want to do, i would find a guy i like while in school. And don’t give up your dreams, cause my LATIN teacher wanted to be a doctor, but she didn’t want all the work cause she was already in a relationship, so she became a teacher instead. NOW, she said she wished she could turn back the clock, and become a doctor, cause it’s her dream. She told me “don’t get married a/f high school, cause it will hinder your chances.”
What the hell are you talking about? Just who told you all this? Your Latin teacher? What the hell does your high school foreign language teacher know about being a doctor? And don’t give me this, “I was supposed to have been a doctor instead.” You just can’t up and decide to go to medical school.
Occasionally, I get real firecrackers such as Landon, a high school sophomore who writes,
I am young,but I am very interested in being a Interventional Cardiologist.I am a 16 yrs old 10th grader… I have the money and grades to be one.
Where the hell did you get that idea? I didn’t even know what an interventional cardiologist was until I was a medical student. And you certainly don’t need money to become a doctor. You just need to make money after you finish medical school to pay back all of those loans.
Another very popular post has been on finding the best college for pre-med studies. Brittany writes in to say,
Medical school is such a challenge. I feel like it is so difficult, and people make it out being such a scary process. I am just a junior in high school, but I feel like I have been stressing out about this every day lately.
Brittany, go into your mother’s medical cabinet and find the bottle labeled either Xanax or alprazolam. Take one of those pills and then go outside and play. Another young reader, Kathleen, shows off her optimistic side:
Maybe then I would be able to set aside money saved from attending the public university honors program in order to help pay for the best medical school that I could be admitted to
Just how expensive do you think college is compared to medical school?
As a follow-up to the “best pre-med school” article, I wrote a piece explaining that there’s no such thing as a “best medical school.” However, that doesn’t stop some people. ATWIINE writes,
PLIZ RANK THE MEDICAL SCHOOLS AROUND THE WORLD FROM THE BEST TO THE WORST. IF I MUST JOIN ANY OF THEM, WHAT ARE THE CONDITIONS I SHOULD FOLLOW.
Arrrggghhhhh… my eyes! What the hell do you think I do all day? This is a personal blog. It’s not some kind of Internet charity.
Sometimes, I get readers who like to dispense advice on subjects they know nothing about, similar to the Latin teacher above. Two years ago I wrote a financial analysis of the military’s health professions scholarship program. While the information there is outdated because of a substantial boost that the program has received, that didn’t stop one dejected father from writing in. Silvanus had to tell me,
my son is a recent undergrad, i was recommending the HPSP to him.
Why the hell would you go and do something like that? Were you in the HPSP program? No? Then don’t recommend something if you’re not familiar with it.
The primary way that I deal with the stresses of medical school is to inject humor whenever I can. I’ve written quite a few fake posts over the past two years. However, not everyone gets that I am writing a parody.
I’ve been asked,
Is this for real?
I provided my e-mail address, would you please sent me information you used to create such a bogus pie graph.
Somebody actually got paid to write this crap?
No, I do it for free. And then there are those who just want to bitch. I’ve written quite a few rants against psychiatrists. Carrie Nation writes,
Your entire blog is confirmation for me that medical doctors, and the pond scum who hope to be one, are no more valuable to our society than personal injury lawyers and auto insurance brokers.
But my favorite coment came from Danielle, a reader who gave a very long objection to my portrayal of psychiatrists, then admitted that shrinks have personality disorders, and finally preceded to talk about her own bipolar condition.
Finally, a recurring theme on this blog has been the suggestion
I strongly suggest skipping residency and getting an MBA.
But there is that rare occasion where one reader writes and says
nice article… thanks
and it really brightens my day.
I am concluding this miniseries on the economics of medicine by examining the cost of doing business as a solo practitioner. Earlier, we saw that living a decent lifestyle requires an annual salary of $170,000. Now let’s see what happens if you’re a solo practitioner and you want to generate that kind of income.
The first thing you’ll have to do when setting up your offices to hire an attorney to help in incorporating your business. You should never practiced under your name alone. Instead of being Half M.D., I should set up a company called Half M.D., PA, to distance myself from any liabilities.
You can get your business to pay the cost of malpractice insurance, health insurance, life insurance, and disability insurance—four things that all physicians will need. The cost of malpractice insurance is highly variable based upon specialty and location. In California, you might pay as little as $10,000. Or you can practice in the absurdly expensive region of Southern Florida where malpractice insurance for ob/gyns runs over $100,000. For my calculations, I decided to use $40,000 for malpractice.
Next, you’ll need to hire an office staff. You will need a nurse or medical assistant, a secretary, and someone who can take care of billing. The total annual cost for salary and benefits for these three employees can run as high as $150,000 depending on the level of talent and experience. You’ll also need to rent a building with enough examination rooms, a private office, and a break room. You can easily spend $5,000 a month on such a setup. You will then have to cover other overhead such as equipment. You can be as bare bones as having just syringes and patient gowns, or you can purchase an ekg machine ($2,000), an ultrasound machine ($100,000), or any number of other office-based equipment depending on your level of practice. I used the calculations below as a bare minimum. You should play around with the numbers for your own situation.
You will see that before taxes, you’ll need to earn over $700,000 a year. As you can imagine, being the only person in the office to pull in that kind of money is going to be very difficult. You may occasionally hear your family practice doctor say that he has not taken a vacation in over six years. He is not being facetious. Every day that you don’t work—whether it be due to an illness or vacation—is a day that you don’t get paid. I will be very generous with my calculations in saying that you are working 250 days a year in this example. If you can get an average of $100 off of each patient thanks to laboratory fees and “bill aboves,” you will have to see thirty patients a day to come out ahead. That gives you 16 minutes dedicated to each patient. I say “dedicated” because you really aren’t going to spend that much time with anyone. Half of your day will be dedicated to paperwork, calling back pharmacists, calling back consultants, writing letters for patients, and other miscellaneous tasks which do not generate money. In reality, you will more likely spend 8 minutes with each patient.
That’s 8 minutes to solve the patient’s new problem, work on health maintenance such as pap smears and cholesterol screening, council about smoking and drinking, consolidate medications, and fulfill any other tasks that the patient needs done. If you’re a pre-med reading this, you may have noticed when you’re shadowing a primary care physician, he runs into the room, looks at the patient’s chart, and quickly blurts out, “I see that you’re here for a headache. Have you had any nausea, vomiting, dizziness, lightheadedness, ringing in the ears, facial pain, difficulty swallowing or talking, tingling of the hands or feet, heart palpitations, urinary incontinence, or erectile dysfunction?”
The patient at this point is staring off into space and manages to say, “Uh, no.”
The physician will then reply, “Good, take this ibuprofen.” And as he is walking out of the room, he glances that the chart and says, “I see that you’re due for a colonoscopy soon. We’ll get that worked out the next time you’re here.”
You now know why primary care is a dying field. Who wants to see 30 patients in a day, only to be the lowest paid doctor?
P.S.: I should add that these calculations were done with the hopes that every patient ends in a full payment. Many insurance companies will not pay you on time, in full, or at all. There is a very real chance that you might have to work extra days to make up for lost income from deadbeat billings.
We’re continuing this miniseries on the economics of medicine by addressing the kind of salary you should be aiming for. While we would all like to believe that we went into medicine for the purpose of helping others, we must not delude ourselves into thinking that “helping others” is cheap. Let’s take a look at the salary that is necessary to maintain a comfortable lifestyle. I’m going to run the numbers given the scenarios that (1) you are single, or at least have a spouse that works, and (2) that you’re married and serve as the sole provider. Let’s say that you purchase a house for $300,000—a reasonable amount in an urban area—and you also purchase a $30,000 car. Assuming a 6% interest rate on each of these items and a 2.5% annual addition for property taxes, PMI, and maintenance, the monthly cost for the house will be $2,423.65, while the car will run $579.98 .
Adding up other components of lifestyle such as food, cable, Internet access, phone bills, and entertainment, we then get the table below for a necessary salary for a single person. I also tacked on the monthly cost of repaying student loans and investing money toward retirement.
Here is the table for a person who is married and serves as the sole provider for the family:
Realize that these numbers are based upon the lifestyle that you choose. They do not reflect an extravagant lifestyle by any means. If you want to belong to a country club or send your children to private school, the numbers will quickly rise from there.
You can claim that you’re willing to live on a salary of $40,000 a year. That you never got into medicine for the money. That you only want to help people and will be happy living from paycheck to paycheck. You’re certainly welcome to live whatever lifestyle you choose, but bear in mind that you still need to make $70,000 a year beyond your lifestyle cost so that you can repay your student loans and save for retirement.
These numbers do not include health insurance, malpractice insurance, disability insurance, or life insurance. If your employer does not pay for these benefits, or you’re a solo practitioner or contractor, you should add the expected costs of these insurances to your total salary. All of a sudden, the necessary pre-tax salary can be well above $200,000, even if you are trying to live on $40,000 a year.
 Calculations taken from mortgage calculator.org.
I’m continuing this miniseries on the economics of medicine by focusing on the important goal every worker anxiously awaits: retirement. Let’s start off by determining what type of lifestyle we want to live when retired. I would like to believe that I would own my home outright. Whether it be in a major urban area or a retiree’s dream home in Florida, we can expect a $300,000 house. Is not unreasonable to assume that I would have to spend 5% of the value of a home each year for property taxes, insurance, and maintenance. Therefore, I should expect to spend about $1250 a month on housing.
If I want to drive a decent car when I’m retired—say, a $30,000 vehicle—I can expect to make payments of just under $600 a month. I can also add monthly payments for food, clothing, medical expenses, Internet access, and a phone bill. Because I’ve worked so hard as a doctor and want to enjoy my retirement, I will expect to spend quite a bit of money dining out and traveling for vacations.
The table below summarizes the monthly expenses I can expect in retirement:
For my particular lifestyle, I will need to earn $52,000 a year from my investments. Given that I should expect to draw no more than 4% annually from my savings, I should retire with $1.3 million in available funds for withdrawal. Since this number is after taxes, and given that I will be in a high tax bracket, I should realistically expect to retire with $2.2 million in savings.
To get to this number, let’s look at how the market has performed historically. Over the past 30 years, the S&P 500 has had an annual rate of return of just over 10%, not accounting for inflation. While there have certainly been extreme ups and downs over the past few years, the market is pretty consistent over the long term. Let’s continue to use 10% as our annual rate of return for retirement investments.
To reach $2.2 million, I would have to invest $12,000 a year for 30 years. Granted, I know very few physicians who can work for a total of 30 years outside of primary care. Many of the physicians I know try to retire after 20 years. Using this number as a timeline, I would need to invest $35,000 a year for 20 years to reach $2.2 million.
Now for the bad news. To become an attending physician, you are going to have to invest 12 years of your life and rack up $200,000 in debt just so you can begin earning a salary that most people in the United States will be ignorantly envious of. Previously, I’ve mentioned that you would have to earn more than $35,000 a year beyond your everyday living expenses so that you could pay off your student loans in 10 years. Now you are going to have to tack on another $35,000 so that you can begin saving for retirement. That’s $70,000 beyond the cost of housing, car payments, food, clothing, health insurance, life insurance, disability insurance, malpractice insurance, and car insurance.
Now for the even worse news. I want you to go to the webpage for your city’s police department. In my area, police officers need only to have earned a high school diploma and reached the age of 18. The starting salary for an officer in my area is $45,000 a year. Just think, you’ll be a resident and working twice as many hours just to make the same amount. Police officers also look forward to gaining other benefits including health Insurance and a pension. Likewise, retired military, teachers, and firefighters can enjoy many years of retirement at the government’s expense by working only a few years relative to the amount of time they will receive entitlement packages.
But let’s take this one step further. Let’s say that a police officer decides to invest $10,000 a year until he becomes old enough to draw Social Security. Assuming the 10% rate of return, he will generate $7.9 million over a 45 year period. If he decides that his pension and Social Security are enough to live on and defers withdrawing any of as investments for an additional 20 years, his total savings will increase to $53 million. And remember, you’re the doctor making the big bucks.
I worked with one veteran in the VA hospital who was retired military, retired police, and had netted himself two pensions and Social Security. He was pulling in $160,000 a year in retirement benefits. Since he was hospitalized with dementia, all of that money went to his family. Not surprisingly, his children were adamant that he be a full code so that they could continue receiving checks. The federal government was the one left with paying the health bills.
I’m kicking off a short series on the economics of medicine this week by expounding upon one of the most important—and depressing—aspects of practicing medicine. I first want to address the elephant in the room. Most medical students will receive their education via student loans. Annual tuition prices for medical school can range from less than $10,000 to well above $40,000. Typically, private schools generally cost around $30,000 a year to attend. Next, add on cost of living expenses. In a major urban area, you might well spend over $1000 a month on rent. Once you tack on food, gasoline, car insurance, clothing, and other expenses, your total bill for medical school might run over $50,000 a year—or $200,000 for the whole degree.
Let’s say that you have $200,000 in debt and that the interest rate for your loan is 5%. You can see from the table below that depending on a how long you take to pay off your loan, the total cost of your education will be close to double what you originally expected.
Even if you were to devote a large portion of your salary to paying off your debt, taking the 10 year route will cost more than $25,000 a year. That’s $25,000 more that you have to earn each year after taxes. Since you’ll likely be in one of the higher economic brackets, you will need to make between $35,000-$40,000 beyond your everyday living expenses just to pay off your loans. Instantly you can see why many people pursue subspecialties where the pay is higher. Why become a primary care physician who will spend 20 years paying off debt, when you could become a radiologist and knock it out in five?